Primary health care in London--changes since the Acheson report.

OBJECTIVE--To examine changes in primary care in London in the 11 years since the Acheson report on primary health care in inner London. DESIGN--Analysis of key data from the family health services authority performance indicators and from the Department of Health; study of trends since the time of the Acheson report; examination of the provision of primary care in 1990-1 and its relation to health and social factors. SETTING--Comparisons between the family health services authorities of inner London, outer London, and England as a whole, with a special study of Birmingham, Liverpool, and Manchester. SUBJECTS--The family health services authorities of England. RESULTS--There has been an improvement in the provision of primary care in inner London as judged by the criteria of the Acheson report, but these improvements have occurred only as part of an overall improvement in the provision of primary care in the country as a whole. None of the recommendations of the Acheson report specifically oriented to London have been implemented. There are some worrying trends in inner London, such as the increasing proportion of practices with more than 2500 patients. The problems faced by practitioners in inner London resemble those in other large inner city areas, but the primary care provision to deal with them is relatively poor.     

Secondary care beyond Tomlinson: an opportunity to be seized or squandered?

The Tomlinson report''s emphasis on primary care and its essentially quantitative analysis of hospital care in London leaves little space for a picture of how secondary care for Londoners should look. In this article Fiona Moss and Martin McNicol argue that most outpatient work does not need to be done in hospitals. With proper organisation and better premises a genuinely specialist consultative service can be provided in primary health care centres, with benefit to patients and communication between primary and secondary care doctors. Hospitals would then house those outpatient services that needed major investigative facilities and much reduced inpatient capacity. It may no longer be necessary for each acute unit to offer a full range of services. Such a pattern of secondary care will have implications for the organisation of accident and emergency services and for postgraduate training. Above all Moss and McNicol argue that Tomlinson''s recommendations demand that general practitioners and specialists should re-examine the services hospitals provide and agree on the best settings for different sorts of health care and the most appropriate skills to provide it.     

Primary care development zones.

Most commentators on the Tomlinson report have agreed with its emphasis on improving primary and community care. The three elements of such a strategy are a remedial programme to bring primary care up to national standards, a programme to provide such services to people with non-standard needs such as mobile Londoners, ethnic minorities, and homeless people, and the development of an expanded model of primary care. No one model will be appropriate across all of London. The process should start with an audit of existing resources and services within each community, together with an analysis of needs. From this would develop a local programme with specific plans for investment in premises, staffing, training, and management. New contractual mechanisms may be needed to attract practitioners, improve their premises, secure out of hours services, and provide medical cover for community beds. There should also be incentives for closer working between primary and secondary services. No developments on the scale needed for London have been carried out in primary care within the lifetime of the NHS--but their success will be critical to the calibre of health services for Londoners into the next century.     

Facilitating care of patients with HIV infection by hospital and primary care teams.

To complement the role of primary care teams working with patients with HIV disease and AIDS within greater London and to ease the load on the special hospital units a home support team was developed. It comprises six specialist nurses, a general practitioner trained medical officer, and a receptionist and is funded from regional and district sources and charities. A nurse is available for out of hours and emergency weekend calls, with support from the patient''s general practitioner or the attached medical officer. During the first 18 months 249 patients were seen; the mean duration of care was five months. Nearly a third (18/50, 30%) of patients who were terminally ill died at home. The team''s activities included practical nursing care, emotional support for carers and patients, and advice and guidance to primary care teams. Problems in providing care in patients'' homes included issues relating to confidentiality and 24 hour cover. With the increasing incidence of HIV infection the home support team may be a useful model for care of large numbers of patients with symptomatic HIV disease, especially in large urban areas.     

Community care in London: the prospects.

Elderly and disabled people have been led to expect great improvements in the quality of community care after April 1993. The choice to live safely at home is to be offered as an alternative to residential care. The financial and organisational relationships are all intended to support this in practice. The Tomlinson recommendations will create instability for providers, and much new and overdue investment in primary and community services is needed if the community care reforms are to work. There are, however, other obstacles looming which pose an even greater threat to the smooth transition after April 1993. The formula by which government money for implementation will be distributed discriminates against London. The sheer complexity of the organisational transformation has also been underestimated; the machinery of government both locally and centrally is ill equipped to maintain the precedence of the consumer. There are examples of good practice in London boroughs, but the dangers of Londoners ending up with the worst of all worlds are great.     

Public health in inner London.

One of Sir Bernard Tomlinson''s aims in his inquiry into London''s health services was to advise the secretary of state for health on the future balance of primary and secondary health care "taking account of the health needs of Londoners." Sir Bernard, however, also made it clear that "we have not seen it as part of our remit to carry out a comprehensive needs assessment for the whole of London," but concluded that the extremes of health need found in London were "unparalleled in the rest of England." Dr Jacobson highlights some of the major determinants of health inequality in inner London and assesses the extent to which the proposed solutions are likely to meet these needs.     

Smart cards--the key to trustworthy health information systems.

Some 20 years after they were first developed, "smart cards" are set to play a crucial part in healthcare systems. Last year about a billion were supplied, mainly for use in the financial sector, but their special features make them of particular strategic importance for the health sector, where they offer a ready made solution to some key problems of security and confidentiality. This article outlines what smart cards are and why they are so important in managing health information. I discuss some of the unique features of smart cards that are of special importance in the development of secure and trustworthy health information systems. Smart cards would enable individuals'' identities to be authenticated and communications to be secured and would provide the mechanisms for implementing strong security, differential access to data, and definitive audit trails. Patient cards can also with complete security carry personal details, data on current health problems and medications, emergency care data, and pointers to where medical records for the patient can be found. Provider cards can in addition carry authorisations and information on computer set up.     

Home accidents in older people: role of primary health care team.

OBJECTIVES--To determine the incidence and nature of unreported and reported home accidents in older people and to investigate associated environmental factors. DESIGN--Postal questionnaire requesting information on home accidents in the preceding month. SETTING--Inner London general practice. SUBJECTS--All registered patients aged over 65 years (n = 1662), of whom 120 were inappropriately registered and 1293 responded. MAIN OUTCOME MEASURE--Circumstances and consequences of accidents in the home. RESULTS--108 accidents were recorded in 100 patients, giving a home accident rate of 84/1000 patients, equivalent to an annual rate of 1002/1000. 73 accidents were falls, and 83 were unreported. Of the 25 reported accidents, 19 were reported to general practice and six to accident and emergency departments (5.6% of all events). Rates of home accidents increased with age and were higher in women than men (79/819 upsilon 29/474; chi 2 = 4.5, df = 1, p less than 0.05). CONCLUSIONS--The incidence of home accidents in people aged over 65 years was high but few events were reported to medical services. General practice provided the main contact for patients who reported home accidents, and primary care workers have important opportunities for advising elderly patients on home accident prevention. Improved publicity on home safety targeted at older people and their carers would support the primary health care team in this role.     

Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates

ObjectivesTo calculate socioeconomic and health status measures for the primary care groups in London and to examine the association between these measures and hospital admission rates.DesignCross sectional study.Setting66 primary care groups in London, total list size 8.0 million people.ResultsStandardised hospital admission ratios varied from 74 to 116 for total admissions and from 50 to 124 for emergency admissions. Directly standardised admission rates for asthma varied from 152 to 801 per 100 000 (mean 364) and for diabetes from 235 to 1034 per 100 000 (mean 538). There were large differences in the mortality, socioeconomic, and general practice characteristics of the primary care groups. Hospital admission rates were significantly correlated with many of the measures of chronic illness and deprivation. The strongest correlations were with disability living allowance (R=0.64 for total admissions and R=0.62 for emergency admissions, P<0.0001). Practice characteristics were less strongly associated with hospital admission rates.ConclusionsIt is feasible to produce a range of socioeconomic, health status, and practice measures for primary care groups for use in needs assessment and in planning and monitoring health services. These measures show that primary care groups have highly variable patient and practice characteristics and that hospital admission rates are associated with chronic illness and deprivation. These variations will need to be taken into account when assessing performance.     

Undergraduate medical education.

Pressures from students and teachers, from professional bodies, and from changes in the way health care is delivered are all forcing a rethink of how medical students should be taught. These pressures may be more intense in London but are not confined to it. The recommendation the Tomlinson report advocates that has been generally welcomed is for more investment in primary care in London. General practitioners have much to teach medical schools about effective ways of learning, but incentives for teaching students in general practice are currently low, organising such teaching is difficult and needs resources, and resistance within traditional medical school hierarchies needs to be overcome. Likewise, students value learning within local communities, but the effort demanded of public health departments and community organisations is great at a time when they are under greater pressure than ever before. The arguments over research that favour concentration in four multifaculty schools are less clear cut for undergraduate education, where personal support for students is important. An immediate concern is that the effort demanded for reorganising along the lines suggested by Tomlinson will not leave medical schools much energy for innovating.     

The role of deputizing agencies in the delivery of primary health care services.

When not available to their patients, family practitioners in large cities can "sign out" to deputizing agencies, which coordinate the activities of part-time physicians on call. The physicians making use of one such agency in Toronto appeared to be representative of family practitioners in the region. One thousand of their patients seen consecutively by one physician were asked a series of questions. The majority of the 811 evaluable patients were considered to have problems justifying an after-hours call, although 16% of the problems were of a trivial nature. However, almost half of the patients with trivial problems would have gone to the local emergency room, as would 85% of all the patients. Although virtually all (94%) of the visits with the elderly were justified, 34% of the patients in this age group said they probably or definitely would not have sought emergency room care if a physician had not been available. The use of deputizing agencies should reduce the overuse of emergency room facilities and provide optimal after-hours primary medical care.     

Patients’ attitudes to the summary care record and HealthSpace: qualitative study

Objective To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care.Design 103 semistructured individual interviews and seven focus groups.Setting Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation.Participants Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants of a drug rehabilitation programme.Methods Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances.Results Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person’s level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for “vulnerable groups.” Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness.Conclusion Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The “implied consent” model for creating and accessing a person’s SCR should be revisited, perhaps in favour of “consent to view” at the point of access.     

Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices

The bulk of mental health services for people with depression are provided in primary care settings. Primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, and they do that with little support from specialist services. Depression is not effectively managed in the primary care setting. Collaborative care based on a team approach, a population health perspective, and measurement-based care has been proven to treat depression more effectively than care as usual in a variety of settings and for different populations, and it increases people’s access to medications and behavioral therapies. Psychiatry has the responsibility of supporting the primary care sector in delivering mental health services by disseminating collaborative care approaches under recent initiatives and opportunities made possible by the Affordable Care Act (ACA).     

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners,senior house officers,and registrars.

OBJECTIVES--To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN--Prospective intervention study which was later costed. SETTING--Inner city accident and emergency department in south east London. SUBJECTS--4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES--Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS--Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor''s manner (434/492 (88%)). Patients'' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION--Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.     

Postal survey of patients' satisfaction with a general practice out of hours cooperative.

OBJECTIVE: To assess patients'' satisfaction with out of hours care by a general practice cooperative compared with that by a deputising service. DESIGN: Postal questionnaire survey. SETTING: A general practice cooperative in London and a deputising service operating in an overlapping area. SUBJECTS: Weighted samples of patients receiving telephone advice, a home visit, or attending a primary care centre after contacting either service in an eight week period. MAIN OUTCOME MEASURES: Patients'' overall satisfaction and scores for specific aspects of satisfaction. Satisfaction with telephone advice or attendance at centre compared with home visit. Relation between satisfaction and patient''s age, sex, ethnic group, car ownership, preference for consulting own doctor, and expectation of a visit. RESULTS: The overall response rate was 67% (1555/2312). There was little difference in overall satisfaction between patients contacting the cooperative or the deputising service, but patients contacting the latter were less satisfied with the explanation and advice received and the wait for a visit. There were significant differences between patients in different age and ethnic groups, with white patients and those aged over 60 years being more satisfied. Lower scores for overall satisfaction were reported by patients who received telephone advice, those who would have preferred to see their own doctor or who originally wanted a home visit, and those who waited longer for their consultation. Overall levels of patients'' satisfaction seemed to be lower than previously reported. CONCLUSIONS: There were larger differences in satisfaction between different groups of patients than between different models of organisation for out of hours care. A shift to a service based predominantly on telephone advice may lead to increased patient dissatisfaction.     

What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base.

Ongoing negotiations on the general practitioner contract raise the question of remunerating general practitioners for increased workload resulting from the shift from secondary to primary care. A review of the literature shows that there is little evidence on whether a shift of services from secondary to primary care is responsible for general practitioners'' increased workload, and scope for making generalisations is limited. The implication is that general practitioners have little more than anecdotal evidence to support their claims of greatly increased workloads, and there is insufficient evidence to make informed decisions about remunerating general practitioners for the extra work resulting from the changes. Lack of evidence does not, however, mean that there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload.     

Empowering GPs as purchasers.

FHSAs have defined their role in purchasing primary care FHSAs have also found themselves intermediaries between district health authorities and general practitioners All of the purchasing authorities recognise the need to educate general practitioners on how to use their influence in the purchasing process General practitioners should be involved in the purchasing process as they purchase the bulk of health care; are the first point of contact for the users of the health service; need to have input on what is purchased; and need to be able to manage the changes resulting from the shift in the balance of power towards primary care The involvement of general practitioners in the purchasing process at present varies considerably among health authorities. Several district health authorities have developed models of purchasing that enable different levels of involvement     

Creating a shared vision of out of hours care: using rapid appraisal methods to create an interagency,community oriented,approach to service development.

OBJECTIVES--To undertake a district wide review of out of hours primary health care services and identify the views of users and providers about current arrangements and options for development. DESIGN--A range of qualitative and quantitative survey methods based on rapid appraisal methods, modified to apply to an inner city district. SETTING--Socially deprived, multiethnic district in south east London with a population of over 700,000. MAIN OUTCOME MEASURES--Strengths and weaknesses of current out of hours services and suggestions for developments. RESULTS--Widespread dissatisfaction with current arrangements was identified, with specific problems relating to access, availability, demand for services, and interagency communication. Several areas for development were identified, including the establishment of an out of hours cooperative, multiagency primary care emergency centres, and telephone advice-triage. Many of these are now being planned or piloted. CONCLUSIONS--Rapid appraisal provided a helpful method, enabling partnerships to be established between local agencies and users in relation to service development. The shared understanding and commitment to improving services that resulted is now having a major impact on out of hours care in the district.     

Bioethics for clinicians: 15. Quality end-of-life care

A physician who receives a call from the emergency department to see a patient with heart failure will have a clear framework within which to approach this problem. The thesis of this article is that physicians do not have an analogous conceptual framework for approaching end-of-life care. The authors present and describe a framework for end-of-life care with 3 main elements: control of pain and other symptoms, the use of life-sustaining treatments and support of those who are dying and their families. This 3-part framework can be used by clinicians at the bedside to focus their effort in improving the quality of end-of-life care.     

Other cities,same problems.

London''s health care problems, particularly underfunding, are mirrored in other major cities in the United Kingdom and abroad. None has found the perfect solution, but the debates on the Tomlinson report provide an opportunity to review how to manage the three major areas of service provision, medical education, and research in London. Mr Robert Maxwell suggests that some aspects of the successful ambulatory care initiative in New York could be adapted by the capital''s primary care providers while the secondary services might learn from the rationalisation of specialist services in Paris.